Soccer or “football” is one of the most popular and participated sports in the world which brings an inherent level of injury risk especially to the lower limb. Anterior cruciate ligament (ACL) injuries are prevalent in soccer with women having a 2 to 3 fold increased risk of an ACL injury compare to males. ACL injuries are a debilitating injury which can negatively impact a players career and long term health of their knee, with up to 75% of players reporting knee symptoms that interfere with their quality of life 12 years after undergoing ACL reconstruction surgery (ACLR).

What Are the Known Injury Rates?

ACL injury rates and reinjury rates in women’s soccer are well reported and reasonably consistent across the literature with a significantly higher risk of ACL injury, ACL reinjury and new knee injury in women compared to controls or non-soccer players.

  • A 2016 study examining the risk of ACL reinjury following ACLR found that 34% of female players who returned to play reinjured their ACL.
  • A 2018 study showed that compared to healthy controls women soccer players had a 5 fold increased risk of a new ACL injury and a 2-4 fold increase in the risk of a new knee injury (cartilage, meniscus); with 62% quitting soccer 2 years after ACLR.
  • A 2020 10 year follow-up study post ACLR showed only 51% of female players return to soccer following ACLR; of those 51% who returned 28.7% reinjured their ACL and 20.6% injured their contralateral (opposite) ACL.
  • A 2021 5 to 10 year follow-up study post ACLR found that 42% of players who returned to soccer following ACLR reinjured their ACL; players who returned had a 2 fold higher risk of a new ACL injury compared to those who didn’t return to soccer and a 4 fold higher risk compared to healthy controls; additionally those who returned to soccer had a 2-5 fold higher risk of a new knee injury and surgery compared to those who didn’t return to soccer and healthy controls.

What Are The Risk Factors For ACL Injuries in Women’s Soccer?

Following a review of the literature it is evident that our understanding on why women experience significantly higher rates of ACL injuries and reinjuries is not well understood yet. It is recognised that ACL injuries are multifactorial with leading considerations focusing on fatigue (which is not well established), anatomical and biomechanical differences such as unfavourable pelvic-hip-knee-ankle alignment, generalised tibio-femoral laxity, a greater reliance on stability from ligaments rather than muscles, low concentric hamstring to quadriceps ratio, hormonal fluctuations. Additional considerations include external hip range of motion and power and age; with injuries in women usually occurring at a younger age than males. Furthermore, there is some evidence to suggest altered landing mechanics and muscle imbalances present at return to play may increase the risk of reinjury in soccer players.

Where to From Here?

With a prevalence of .9-2.2 ACL injuries per 1000 match hours in women’s soccer and significantly higher rates than men, in addition to higher reinjury rates it is pertinent to understand why women are at a higher risk of an ACL injury. If we can identify the key risk factors associated with ACL injuries in women’s soccer it will enable clinicians to more accurately establish those players who are at a higher risk of injury or reinjury, help to refine pre participation assessment examinations, injury prevention programs and rehabilitation programs, as well as strengthening return to play criteria.

ACL injuries can be devastating and career changing injuries which is reflected by the high number of players who do not return to the pitch following ACLR. The best way we can protect our female players is to do our best to prevent these injuries from occurring and make sure they are rehabilitated to the best of our current knowledge to minimize the risk of reinjury. As ultimately, we want to see more women part taking in physical activity and enjoying team sports like soccer.